Physiotherapy and Yoga

The Yoga Therapist Will See You Now

Amanda Koster for The New York Times

FLEX TIME: Lynn Hughes, left, an assistant therapeutic yoga instructor, and a client, Barbara Morgan, at the Yoga Barn in Issaquah, Wash. Ms. Morgan’s goal is to restore full motion in her upper body after a double mastectomy.

FOR three years after a car crash left her with chronic pain, Deanna Adams searched high and low for relief. Mrs. Adams, 41, a stay-at-home mother in West Palm Beach, Fla., consulted a physiotherapist, a chiropractor, two doctors (a pain specialist and a neurologist) and an acupuncturist — to no avail.

Charity de Meer for the New York Times

A STRETCH Emily Large works with Deanna Adams in West Palm Beach, Fla.

She also went to basic yoga, hoping asanas would ease the debilitating back pain, neck spasms and migraines that plagued her. After each class at LA Fitness, Mrs. Adams felt better for a few hours, but her symptoms inevitably returned.

It was only after her first yoga therapy session with Emily Large, who runs Living Large Therapeutics, that she realized why group yoga left her cold. “When you go to a yoga class, everybody is doing the same thing,” Mrs. Adams said. “If you have a neck or back injury, the instructor doesn’t know.”

Yoga therapy — one-on-one visits which take place in medical clinics, physiotherapist offices and yoga studios — takes into account pain and injuries for a customized experience.

As her client did yoga postures she had handpicked, Mrs. Large, a yoga therapist with a physical therapy license, lightly touched her to sense where Mrs. Adams was tense or weak. Then she designed a sequence of poses to target those areas, including a lying twist with the knees bent and a repetitive variation of triangle pose. As Mrs. Adams grew stronger and more flexible doing poses at home, her routine was updated, and after three months, her pain has largely subsided.

People often turn to yoga when they are injured because they want gentle exercise that’s easy on the joints. But, most yoga teachers don’t have time to address individual problems, nor do they regularly deal with special needs.

Enter yoga therapy, an emerging field in the United States, although commonplace in India. Therapists work in small groups or privately, adapting poses for musculoskeletal problems that have been diagnosed by doctors. Other therapists help people deal with the anxiety of living with illnesses as varied as cancer and chronic fatigue.

“We recognize that not every pose is for everybody,” said Robin Rothenberg, a yoga therapist who runs the Yoga Barn studios outside of Seattle. “If you are a 20-something dancer, that is one thing and if you are a 50-year-old computer programmer, that’s a different thing.”

Yoga therapy is nowhere near as popular as one-pose-fits-all classes. Still, in the last three years, membership in the International Association of Yoga Therapists, a trade group based in Prescott, Ariz., has almost tripled to 2,060, from 760.

But experts inside and outside the industry say yoga therapy should be approached with caution. In general, a person can practice as a yoga therapist after 200 hours of yoga teacher training, which might include basic training in anatomy, breathing, meditation and giving adjustments.

“Anybody can hang their shingle and say they are a yoga therapist,” said Julie Gudmestad, a physiotherapist who also practices yoga therapy in Portland, Ore. “Buyer beware. I’ve seen some strange things done in the name of yoga therapy.”

Most reputable yoga therapists have additional credentials. Some are physiotherapists or nurses or have completed two years of training in Iyengar yoga, which emphasizes anatomy and kinesiology.

Others have been certified as therapists by schools like Integrative Yoga Therapy or American Viniyoga Institute. The institute is run by Gary Kraftsow; applicants must have completed 500 hours of his teacher training. His course teaches the clinical applications of yoga for spine, joint and muscle problems.

There is no national credentialing system, and the lack of industry-wide standards worries doctors. “You need some core set of certification that allows a patient to know that they are going to someone from whom they can reliably get appropriate treatment,” Dr. James Weinstein, chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and the editor of the medical journal Spine. “I have certainly seen patients asked to do positions that have made them worse.”

Just as certain conditions can be helped by extension, flexion, twisting or side bending, they can also be aggravated, said Robert Forster, a physiotherapist in Santa Monica, Calif.

Some doctors advocate its use, however. “I deeply believe in yoga and know the therapeutic value of yoga for health care,” said Dr. Michael Sinel, an assistant professor of physical medicine and rehabilitation at the University of California, Los Angeles, who has a private practice in Santa Monica. In the next six months, he plans to start YogaMed, a company that will offer medical care and therapeutic yoga within the Yoga Works chain of studios.

There is some evidence that certain yoga poses help alleviate chronic back pain. A randomized, controlled study published in the Annals of Internal Medicine in 2005 found that participants who followed a pose sequence designed by a yoga therapist improved function more than those given a self-care book or sent to exercise class. (The 101 participants did not include patients with sciatica, previous back surgery or pregnant women.) Now, the National Institutes of Health has allocated $1.2 million for a second study to see, in part, if the results can be replicated on a larger scale.

Yoga therapists are not qualified to diagnose injuries, although some do, said Leslie Bogart, a yoga therapist in Santa Monica, who has worked as a nurse. “Everybody should be seen by a medical person first, without question,” Ms. Bogart said. “Yoga should be an adjunct to” treatment, not “a replacement.”

A handful of doctor’s offices already offer therapeutic yoga. Dr. Loren Fishman, who runs a physical medicine and rehabilitation practice in Manhattan, studied Iyengar yoga in India before medical school, and now recommends poses to patients like Sharon Williams.

Ms. Williams, 46, a development director at Dance Theater of Harlem, suffered from chronic shoulder pain. An M.R.I. revealed a torn rotator cuff, for which Dr. Fishman prescribed, among other things, a variation of a headstand using a chair. This pose can help relieve pain and restore range of motion, yoga therapists say, because of a method called muscular substitution — training the body to avoid aggravating an existing problem by using other muscles.

This is plausible, said Dr. J. Hearst Welborn, an orthopedic surgeon in San Pablo, Calif. He added that actively trying to recover helps: “Mind over matter has a huge effect on people’s pain.”

Longtime yoga therapists say the next step for them is learning to work with doctors. Larry Payne, who has practiced since 1982 and is the founding president of the yoga therapist association, said therapists need to learn to read medical reports and to work in clinical settings. “The doctors aren’t interested in Sanskrit, they just want to be sure that yoga therapists they work with are properly trained,” he said.

To that end, Dr. Payne created a yoga therapy teacher training course at Loyola Marymount University in Los Angeles, where students learn yoga therapy for both systemic and muscular ailments.

Dr. Payne and Dr. Richard P. Usatine also started yoga classes for medical students at the David Geffen School of Medicine at U.C.L.A. “Once they understand and can feel the value of yoga personally, they can then suggest and prescribe it for their patients,” said Dr. Usatine, a professor of family medicine at the University of Texas Health Science Center at San Antonio.

In the United States, yoga is provided at 93 percent of 755 integrative medical centers, facilities offering under one roof both traditional medicine and other approaches to health and wellness.